NANTUCKET, Mass. – Situated 30 miles at sea in a facility nearly 60 years old, Nantucket Cottage Hospital (NCH) has been serving its island community for over 100 years, with the facility being the only healthcare option for its 11,000 permanent residents as well as 60,000 seasonal residents.

The island’s new 120,000-sqaure-foot, 14-bed hospital is a right-sized facility that seeks to transform the patient experience and increases access to providers.

The new NCH confronts the shifting seasonal populations as well as fluctuating weather patterns to ensure functionality throughout all conditions.

Ultimately, NCH selected Cannon Design of Boston to build a hospital that can withstand even the most severe weather events, including hurricanes. NCH is designed to be the “last building standing,” prioritizing safety and resilience and is said to be able to withstand Category 5 hurricanes and up to 185 mph winds. The facility is scheduled to be open to patients by the end of 2018.

Mike Cavanaugh, sustainability leader at CannonDesign, spoke to HCO News to discuss hurricane preparedness and hurricane-resilient design.

Q: What are the standard operation plans for hurricanes in healthcare facilities?

Cavanaugh: Emergency plans vary depending on location, climate and the acuity of patient population served. For inpatient hospitals these emergency preparedness plans can range from partial shut-down and of non-critical care functions to maintaining full operations with supplies and plans for temporary housing of housing medical staff. We work with our clients to ensure first that they have a plan and then we to design toward it. One way we are able to assist in that is by providing natural disaster impact risk (or resilience) assessments. For example in coastal Massachusetts, the primary risks may be storm surge, flooding and high winds. In California, however, we may be more focused on extended drought and wildfires. In some cases, as we see more frequently, now, these plans may tie in to a larger regional strategy with other healthcare facilities and local governments.

Q: What are some design techniques/features a facility can incorporate to prepare for/withstand hurricanes?

Cavanaugh: It’s not just about preparing for hurricanes, it’s designing hospitals to be resilient to storms, climate change, new technology, power loss and more. When we think of storms, the most common design features of resilient structures are investing in windows and materials that can withstand intense winds, flood walls, elevated power sources and patient floors, to name just a few. A few other things building owners should consider:

• Invest in future weather prediction. Designers and building owners can use tools like the U.S. Climate Resilient Toolkit to model which climate changes will create new environmental conditions over time. Then, they can design hospitals to not just be resilient to current challenges, but those that will develop in the future. They could also consider accessing personal weather stations that can help the staff to prepare for upcoming weather events. This should ensure that workers are aware of any extreme weather that is forecast.
• Embrace redundancy. Loss of power is always a threat to healthcare facilities and failing to design redundancies into power systems can leave health facilities without power for extended time or during severe weather events. Critical to any resilient design solution is the incorporation of multiple redundancies into a building’s power infrastructure via generators and on-site reserve fuel for these challenging moments

Q: What specific supplies/services are in place at Nantucket for emergency weather conditions? Are there any innovative electronic/technological systems integrated into the facility for hurricane preparedness/protection?

Cavanaugh: Nantucket Island and its residents face unique challenges. Given its location in the Atlantic Ocean, NCH must regularly deal with inclement weather. The new hospital is designed to withstand potentially catastrophic conditions and provide critical services while “off-the-grid” when weather cuts off access to the mainland, Prepared to be the “last building standing” the facility is equipped with dual fuel electrical generating capacity to provide system redundancy, mechanical elements well above grade in case of severe flooding, materials to withstand 150 MPH hurricane winds, and operable windows for ventilation in the event the HVAC loses power.

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That is why, Jim Perry, chief technical officer of New York-based Cerami & Associates, addresses the problem of noise pollution within healthcare facilities by using the Lunder Building in Boston as a case study.

His webinar, “The Importance of Acoustics on Patient Care: A Case Study on The Lunder Building,” offers real answers to this pressing healthcare challenge. Perry has created a discourse covering different methods to cut vibration levels, reduce major noise sources such as HVAC systems, improve the sound-isolating performance of doors and even addressing intrusive noise from the outside. Using the Lunder Building’s 535,000-square-foot, 150-bed mid-rise hospital tower as an example, Perry can address the impact of building acoustics on both caregivers and patients.

HC+O News spoke with Perry to get the inside scoop on why the Lunder Building is such a prime example of how to reduce noise pollution in healthcare facilities.

Q: For those unaware of this issue, what is “noise pollution,” and why is it being addressed in healthcare facilities? What constitutes an “acoustically healthy” environment?

Perry: In healthcare facilities, high noise levels can be a detriment to patients and staff in different ways. Limiting the noise impacts on patients is critical to promote resting, which has a direct correlation to healing, the ultimate goal. In regard to the staff, high noise levels contributes to higher stress levels and increases the possibility of mistakes being made in all aspects of their job.

Q: What are some of the key design features of the Lunder Building that mitigate or prevent noise pollution? When did the project of this new design begin?

Perry: There were many aspects of the planning of the space that were utilized to reduce the noise impacts on the patients, distributed nursing stations, minimizing proximity of back of house spaces and doors to patient rooms, location and types of alarms and notification systems all aimed at reducing the noise impacts on the patients. The design for this began with NBBJ utilizing these planning methods before 2006.

Q: What are the biggest challenges in designing a healthier noise environment? How can other facilities work towards implementing these designs, and are there any future plans for extending this to other healthcare facilities? 

Perry: The biggest challenge is that the noise levels are due to not only the built environment, but also the staff behavior and operations, so there are multiple avenues that need to be addressed in order to achieve a better environment. This requires a change in typical behavior from the staff, which is not always possible.

According to a statement, Perry has 17 years of experience providing acoustical and vibration consulting for varying project types. Perry has gained special expertise in areas of mechanical system design and vibration control, especially in the design of large scale developments, residences, and healthcare facilities. Perry has appeared as an expert witness at Community Board hearings in both New York and New Jersey, offering testimony on noise transmission, with regard to noise codes, residential impact issues, and other acoustical and vibration issues. He is fully conversant with all aspects of architectural acoustics, mechanical systems, noise and vibration control and environmental impact assessment.

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The projects will construct two 300-bed secondary care hospitals, the buildings will not only accommodate patients, but also staff and parking facilities as well. One hospital will be located in Al Ahmadi and the other will located in Al Jahra.
The projects were established by Health Assurance Hospitals Company (Dhaman) as a public-private partnership in response to a need for secondary care facilities. Mohammed Al Rais, regional president in the Middle East for Hill International, will manage the partnership.
Al Rais has nearly 30 years of experience in project management and development. He earned a Bachelor of Science in city and regional planning from the University of Engineering and Technology in Pakistan and a Master in Science in project management from the University of Reading in the United Kingdom.

“We look forward to helping Dhaman deliver these important hospital projects,” said Al Rais in a statement.

Since there is such a strong need for secondary care facilities in Kuwait, these hospitals are being built in response to Kuwait’s National Healthcare Expansion Plan. The plan is designed to cater to the growing population of Kuwait, a population that is expected to increase drastically in the next two years.

“We understand the importance of timely delivery for these types of health care facilities and we are confident that our team will meet or exceed all expectations,” said Al Rais in a statement.

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The project was designed by BSA LifeStructures, while McGrath & Associates served as the construction manager, with both companies operating out of their St. Louis offices. The facility was constructed in an area adjacent to the previously existing MRI rooms, which continued to function until the project was completed and the machines could be moved to the new site.

“Managing the project phasing was a challenge,” said McGrath Project Manager Jamie Gensits. “We made sure that the MRI staff could maintain excellent patient care throughout our construction process.”

McGrath installed a copper enclosure to prevent radio frequency and electromagnetic interference from penetrating the room. An MRI works by manipulating radio frequency fields in the body to produce a magnetic field that the machine can detect to create an image. This means outside sources of radio or electromagnetic waves can cause interference, limiting the clarity of the resulting image. Copper conducts electricity very effectively and tends to absorb rather than reflect it. This makes it ideal for keeping outside radio and electromagnetic waves from passing through the outer walls and penetrating an MRI machine. Other efforts included using an isolated electrical ground. Usually electricians can use one ground for multiple electrical devices, but the sensitive nature of an MRI machine makes this a bad idea, as electrical interference can result from connecting other devices to the same ground as the machine.

McGrath also employed electrical filters, which filter extra electrical frequencies that might be conducted by wiring and waveguides. This corrals electromagnetic waves and channels them through a narrow pipe. These measures were taken to make sure wires and cords don’t accidentally guide additional interference-producing waves into the machine.

The new machine also has to be supported in a way that eliminates vibration transfer between the structure and the massive magnet the machine relies upon. This stops movements in the structure, caused by shifting or a bus driving by, from being absorbed by the highly sensitive magnet, which would also cloud the picture.

McGrath used a special mixture of fast-setting concrete to speed the construction process, helping the project move from inception in December of 2011 to completion in June of 2012.

BSA LifeStructures is a design firm that specializes in health care, higher education and research institutions. McGrath & Associates is a general contracting company specializing in commercial, health care, industrial, institutional and pharmaceutical construction projects.

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UH comprises the largest health care system in the Northeast Ohio region and is affiliated with Case Western Reserve University. The network includes more than 24,000 employees, performing more than 4.5 million outpatient procedures and nearly 63,000 inpatient discharges annually. The new structure is one of the 12 freestanding cancer hospitals in the nation that has earned the National Cancer Institute’s rating as a Comprehensive Cancer Center.

The 375,000-square-foot, 10-story facility cost $260 million and was named in honor of Jane and Lee Seidman, who donated $42 million to the effort — the largest single donation in University Hospitals’ history. Lee Seidman founded The Motorcars Group in 1958, which went on to become one of the nation’s largest networks of auto dealerships. The pair have been active philanthropists ever since, and are particularly interested in cancer research.

“Jane and I have been fortunate with a successful business and that, coupled with the tradition of giving passed along to us by our parents, has provided us the inspiration to give back,” Seidman explained in a statement. "Cancer has impacted many of our loved ones and we are overjoyed to make this gift that may lead to finding cures for cancer.”

The new building consolidates all the cancer services at the medical center into one location. The structure also triples the size of areas dedicated to cancer-related services at the campus, adding 120 beds to the operation, with capacity to accommodate 30 more, if needed. The structure fits into UH’s $1 billion fundraising campaign, Discover the Difference, which has raised $685 million since it began in 2003.

The first visual aspect to jump out at most visitors will be the building’s striking curved face, which resembles the wall of a futuristic half-pipe, like those used by skiers or skateboarders in the Winter Olympics or X Games. This design allowed for larger lobby spaces and treatment areas to be installed in the lower levels, while also giving the structure a futuristic, otherworldly appeal. The design also allows for an abundance of natural lighting, as the entire face of the building is teeming with extremely wide windows.

The effect was achieved through collaboration between Bridgeton, Mo. firm Universe Cladding Solutions (UCS) and Huron Valley Glass of Ypsilaniti, Mich. UCS fabricated 59,000 square feet of Reynobond natural brushed aluminum composite material specifically for this project. This was the only natural metal composite material on the market that would allow for 62-inch wide sections, which were required by the design. Most of the panels were prefabricated and installed as-is, but the sections for the curved area had to be formed individually using hot air welding.

The panels were installed in Universe Cladding’s U2000R dry-joint rain screen system, as it allowed for the curved shape and also makes future repairs easier. Each panel can be removed separately, rather than having to remove entire sections of paneling to work on one of them.

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Jordan Lerner, regional director of sales and engineering for Schneider Electric, explained that several changes, such as lighting retrofits, occupancy sensors that control when lights are on, and automation systems that optimize power use, all serve the dual purpose of expending less energy and extending the life of equipment the hospital depends on. Lerner compared automatically turning equipment off when not in use to having fewer years on a car’s odometer; the product will simply last longer if it isn’t running when no one is using it. He added that the automation system would not only regulate electrical use to match the facility’s daily and weekly schedules, but would also make seasonal adjustments throughout the year to adjust for the effects of the outdoor environment on the controlled climate inside the building.

Lerner said one of the more unique features was an ultraviolet light system that eliminates many possible biological contaminants that the ventilation system might pull in from the outside air. He explained this was a feature rarely seen outside of the medical world.

Lerner commented that his company went into each project with the most open-minded approach possible. He said Schneider often used products and services that his company used in the past and trusted, but was willing to try something new depending on the client’s needs and wishes. He said the staff at the memorial hospital brought an equal degree of open-mindedness, which benefited the project greatly. Lerner explained the hospital staff wanted to go for efficiency upgrades with the fastest return on cost-savings possible, but signed up for a long-term approach when they learned how much more cash would be preserved with that approach. He felt that many hospitals focused less on green features than other industries because they often faced financial decisions between structural upgrades and medical equipment, but this facility seemed to buck that trend and embraced the long-term view on cost savings.

Lerner felt that one of the least recognized functions of a retrofit company like his was to serve as a mediator between various interests at a hospital, bridging the gap between the boardroom and the boiler room. He said this part of the operation went particularly smoothly in this case, as all sides seemed interested in working together to find the best solution.

Jim Poffinbarger, director of the hospital’s environmental services department, said the feeling was mutual. “Based on our time working together, we feel that Schneider Electric is best equipped to assist us in reducing our energy use and creating a more sustainable hospital that better serves our patients and staff while demonstrating our commitment to energy efficiency and environmental responsibility.”

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The entryways to Tulane Medical Center may be sandbagged because of Hurricane Isaac, but that doesn’t mean they aren’t accepting patients. Emergency room staff and a skeleton crew medical team have been braving the weather every day, treating almost as many patients as they would under normal conditions.

The city has offered to transport people with special medical needs to state shelters, but many proud citizens don’t want to leave their homes, meaning the hospital is seeing patients who have experienced failures in their home medical equipment due to power outages or other issues.

Though hospital staff, as always, is more than willing to bite the bullet and brave the storm, Tulane emergency room medical director, Dr. Prateek Adhikari, told the Times-Picayune there were multiple reasons for citizens with chronic medical issues to follow authorities’ advice and accept the governments offer to relocate them as storms approach. In addition to the risks involved in staying home when power and water services will likely be disrupted, and the dangers of being forced to brave the storm if help becomes necessary, Adhukari explained, “People need to be aware that hospitals are not running on all eight cylinders.”

He added that the medical center’s intensive care unit was already filled. The problem was compounded by a case of good old fashion bad luck, as the hospital would have preferred to release more patients as the storm approached, but happened to have a higher than normal number of patients who were severely ill and simply couldn’t be released in good conscience.

Despite these obstacles, the hospital’s diligent preparation for the storm has made the difference. The pharmacy stocked up in the days before the storm, in anticipation of the increased difficulty, if not outright impossibility, of delivering additional supplies during a severe storm.

The hospital also received assistance from its majority owner, Healthcare Corporation of America, which has provided its medical centers in the region with special weather updates, extra supplies, and emergency evacuation contracts with various types of aircraft.

Though Hurricane Katrina remains a haunting memory in the minds of a nation, its clear that many lessons have been learned from the region-shattering event in terms of preparedness for severe storm events. The river may rise, but the people will too.

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Complicating the difficult task of maintaining facility security are a host of other challenges for facilities managers, such as reducing operating costs, meeting complicated compliance and regulatory issues, maintaining ageing fire and life safety systems so that local fire inspection businesses, who often use the Inspect Point software, will pass them and supporting an open and welcoming environment.

By its very nature, a hospital offers security challenges not presented by other types of facilities. Many people visit hospitals every day for various reasons, for example. The large crowds of people going in and out of hospitals make them vulnerable to attacks and crimes. The security guard can help in keeping track of the people entering and moving out of the hospital. Hiring a hospital security guard from Main Event Security or a similar company can be one way to ensure that people and property in the hospital are safe Most remain open 24 hours a day, accept patients in highly stressed situations and maintain valuable equipment and pharmaceuticals on-site. So how can a health care facility manager meet these added challenges while preserving a high level of security for patients, visitors, clinicians, staff, equipment and supplies?

There is no simple “one size fits all” solution. However, significant advances in security technology are now available.

One such advance is a solution known as physical security information management (PSIM) software that collects and combines information from existing disparate security and even building automation systems into one integrated, intelligent system.

PSIM solutions were developed with input from many industries, including that of facility managers from health care facilities, both large and small. When asked to identify the top challenges to effective hospital facility management, a distinct trend emerged. Facility managers reported struggling to manage dozens of systems without an effective way to integrate them into a single, manageable point of control.

Hospital facility managers using a PSIM solution can now have one complete view of information to quickly analyze data from systems such as video, access control, fire alarms, visitor and identity management, infant abduction, radio frequency location services, intrusion alarms and heating, ventilation and air conditioning.

The PSIM software solution collects and correlates data from these subsystems and then analyzes and automates actions based on predefined standard operating procedures. By consolidating security control and monitoring activities, PSIMs can help to achieve a measurable return on investment.

Above and beyond security and life safety systems, PSIM also opens the door to integrating advanced building automation systems (BAS) that go beyond security to further increase patient safety, comfort and satisfaction.

Here is an example of how a PSIM-BAS integration can help to quickly resolve an emergency and/or prevent injuries. When the fire alarm system detects a fire, the PSIM software signals the access control system to unlock doors along the escape route, direct surveillance cameras to record the region in which the event is taking place, and provide first responders with a live feed as they approach the site. Meanwhile, through BAS integration, the HVAC systems are signaled to stop delivering fresh air to the area and pressurize the path of egress to clear it of smoke.

With its ability to work with existing security equipment throughout a health care facility, a PSIM solution allows for the update and modernization of equipment and systems as budgets allow. A PSIM solution can often eliminate the need to rip out and replace security systems due to its ability to integrate with existing commercial-off-the-shelf security equipment and systems, allowing organizations to leverage those previous investments. Moreover, automating such systems might call for the use of allen bradley parts or other electrical automation parts that are specially manufactured to improve automated functionality and can be tweaked or replaced as necessary, making it a worthwhile investment.

To get started with a PSIM solution, a system integrator works with the hospital facility manager or security director to identify security policies and procedures and then turn them into computer automated rules. These rules can be very specific and prescribe different responses to events in the main lobby, the emergency department and the pharmacy.

By automating the detection, validation and resolution of security alarms and events, false alarms are reduced or eliminated. Fewer employees are required for monitoring a command center. And a PSIM’s single operating platform reduces the amount of time previously required to train operators to use and correlate data from multiple, independent systems.

PSIM software offers full security management capabilities unlike video management or access control systems that offer only limited levels of integration, while typically requiring the inclusion of the manufacturer’s products that do not integrate with competitive systems due to proprietary protocols.

PSIM is a middleware that is designed to allow communication and data management between the many, often proprietary, systems. A growing number of vendors now provide that critical layer of software that enables true PSIM capabilities.

However, as the demand for health care-based PSIM solutions grows, there are still many system integrators unfamiliar with this relatively new security tool. So when it is time to review your facility’s security and building system management processes and procedures, be sure to leverage the expertise of a system integrator with PSIM and health care facility experience that can help make the transition to this new technology as seamless as possible.

Mike Webster, CPP, is manager, global security center of excellence for Milwaukee-based Johnson Controls. The company operates six centers of excellence locations in the U.S., Asia, Europe and the Middle East to serve its field offices in over 150 countries.

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Arizona State Forensic Hospital Delivers on Design and Treatment

PHOENIX —The new Arizona State Forensic Hospital in Phoenix was designed to replace the existing 1952-built Forensic Hospital, which was comprised of 10 antiquated structures. The hospital is a secure housing and treatment facility for psychiatric patients who are found guilty of crimes but because of mitigating factors of mental illness, would not enter a state prison.

The forensic units house persons who are sent to the state hospital from the county court system. Either judged Guilty Except Insane (GEI) or to be Restored To Competency (RTC) or having been. These are persons who are found guilty of criminal behavior, but because of mitigating factors due to mental illness, they are not sentenced to a prison. A small percentage of the patients, fall under “not guilty, by reason of insanity,” which is an older verdict and no longer a current Arizona state law, but a small number remain under this sentencing.

The buildings have state-of-the-art security to protect patients, staff and visitors. The hospital is also a treatment facility and its design and programming space allows for diverse treatment options and individual-based opportunities for treatment.

The new 80,000-square-foot facility was given a budget of approximately $32.2 million, but after the project was complete it came in under budget at $24 million. Cannon Design worked on the project, with associate principal Carl Hampson responsible for much of the design work at the facility, which opened in September 2011. Providence, R.I.-based Gilbane Building Company served as the general contractor for the construction management at-risk delivered project.

Greg McCormick, senior project executive for Gilbane Building Co., has specialized in health care facility construction for 28 years. He explained that the hospital’s security systems were unique, but the masonry construction was the same as what you would find in a traditional hospital.

Gilbane worked with the design team and the Arizona Department of Administration, which oversaw the job, to maximize the program and deliver the most beds for their budget. Through value engineering and constructability ideas, Gilbane was able to help enhance the program.

“Ultimately, we gave them 120 beds at a cost of $23.5 million, which includes soft and hard costs,” said McCormick. “The facility is high security, but the Arizona State Hospital did not want it to look like Department of Corrections project. They wanted it to look like a hospital treating patients.”

There are cameras, card readers and detention hardware throughout the structure, which includes hardened patient rooms. Norment served as the security equipment contractor and BGA as the security consultant.

As for the perimeter security, Howard Pearsall, designer of security electronics, at Norment, explained that the fence is protected with an intrusion-detection system, which was not in the original project scope. Norment’s contract, valued at approximately $1.6 million, includes the touch-screen controls to monitor movement.

Cannon Design has worked on several secure forensic hospitals in the past, but this was the first for Hampson.

“Just like any building design project that we do, you want to make them as nice as possible despite the function and restrictions that are dictated by the security and safety requirements,” Hampson said.

The design and construction of the new specialized high-security facility provides patient rooms with adequate support areas including isolation rooms, multipurpose rooms, and centralized nursing stations, which allow clear views of patient areas, meeting rooms, testing and evaluation areas, visitor’s center, kitchen/dining, security control and command center, therapy areas and sallyport.

The facility was also designed to suit the Arizona climate with a large focus on water and energy reduction, including installations of low-flow toilets and using recycled materials during construction. The hospital promotes a Zen-like atmosphere to help with healing and rehabilitation.

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Hospital Corporation of America (HCA), a fast-growing health industry powerhouse that runs more than 160 hospitals, is not one of these “normal” companies. Although many people feel America lost its pioneering spirit when we ran out of “new world” to discover, we still live in a society and economy that prides itself on taking risk, and gives massive rewards to those who survive those risks. HCA is definitely one of those companies that believe the risk is worth the reward and, given that it has had two governors and a senator’s family involved at various stages, it seems to have the brain trust needed to walk the regulation tight rope.

The particular risk that HCA signed up for was a policy shift in 2008, when the company changed the billing codes for the emergency rooms in its hospitals. Basically, the company changed its policies in a way that would move more emergency room patients into the column for those who need additional care. Patients in that column earn hospitals significantly more Medicare funds. HCA took a giant leap, going from an organization that had less of those patients than the industry standard, to one of the leaders. On the other side of the emergency room equation, HCA began requiring upfront pay for patients who show up at the ER with nonurgent conditions, like a turned ankle or the common cold. These adjustments address the two main issues hospitals face; too many patients never pay and too often the reimbursement hospitals do receive are not nearly significant enough to make up for that gap in funding.

HCA’s Medicaid strategy isn’t very surprising, given that it is owned by three private equity firms, including Bain Capital, Mitt Romney’s highly successful company. Former U.S. Senator Bill Frist’s family also bought a sizeable share of the company, coming full circle as his father and brother originally founded the company. The other two buyers were Merrill Lynch and Kolberg Kravis Roberts. These financial companies have become extremely adept at maneuvering through the complex regulations on Wall Street, and are taking the same approach here, as the three firms have more than tripled their initial $33 billion investment.

Now that someone has taken the initial leap, other investment firms are flocking to follow HCA’s success, buying up hospitals at a rapid pace. It is hard to overstate just how much larger that leap was for HCA, which made this change despite previously settling a Medicaid fraud case for over $1.7 billion, the largest sum the government has ever gotten in a health care fraud case. The settlement was accompanied by the resignation of current Florida Governor Rick Scott from his position as chief executive at HCA, although Scott was not one of the four people indicted during the case. Though some would say HCA took a significant risk by trying to find cost savings in an area related to Medicaid funding after that incident, it has clearly penciled out so far. The company has literally gone from being featured in Forbes Disaster of the Day column to becoming an industry giant and a poster child for privatization of hospitals.

Though HCA is controversial, it currently appears to represent the future. As hospitals struggle with the financial downturn, they become more focused on two major issues, crowded emergency rooms and the constant battle to lower the financial impact of providing services for people who will never pay their bill. Until someone else comes up with a better idea, HCA’s model will probably continue to drive industry trends.

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